When should Candida in the urine be considered pathogenic?

From the Guidelines

Candida in the urine should be considered pathogenic when accompanied by symptoms of urinary tract infection, such as dysuria, frequency, urgency, or suprapubic pain, or in patients with risk factors such as immunosuppression, diabetes, indwelling urinary catheters, recent antibiotic use, or urinary tract abnormalities. Asymptomatic candiduria in otherwise healthy individuals is often a colonization rather than true infection and typically doesn't require treatment 1. For symptomatic candiduria, fluconazole 200mg daily for 7-14 days is the preferred treatment, as it achieves high concentrations in the urine and is effective in eradicating candiduria 1. In catheterized patients, removing or changing the catheter is essential when possible, as this can help eliminate the source of infection 1.

Key Considerations

• The presence of pyuria, hyphae (rather than just yeast forms), or multiple positive cultures increases the likelihood that the Candida is truly pathogenic rather than a contaminant 1.
• For critically ill or immunocompromised patients, treatment is recommended even when asymptomatic, with fluconazole or, for resistant species, echinocandins or amphotericin B bladder irrigation 1.
• Candiduria represents either contamination, colonization, or true infection, and distinguishing between these is crucial for appropriate management 1.

Treatment Options

• Fluconazole is the drug of choice for treating Candida UTI, due to its efficacy and ability to achieve high concentrations in the urine 1.
• Amphotericin B deoxycholate can be used as an alternative, particularly for patients with fluconazole-resistant species, but its use is limited by toxicity and the need for intravenous administration 1.
• Echinocandins may be effective in treating Candida UTI, particularly in patients with fluconazole-resistant species, but their use is not well established and should be considered on a case-by-case basis 1.

From the Research

Candida in Urine: Pathogenic Considerations

• Candida in the urine is not always considered pathogenic, as it can occur due to contamination, colonization, or asymptomatic carriage 2, 3, 4
• However, in certain cases, Candida in the urine can be an indication of a urinary tract infection, such as cystitis, pyelonephritis, or disseminated candidiasis 3, 5, 6
• The presence of Candida species in urine in asymptomatic patients does not warrant antifungal therapy, except in certain high-risk groups, such as:
  • Neutropenic patients 3
  • Very low-birth-weight infants 3
  • Patients undergoing urologic procedures 3, 6
• Risk factors for the development of candiduria include:
  • Indwelling urinary catheters 2, 3, 5
  • Broad-spectrum antibiotics 2, 3, 6
  • Diabetes mellitus 3, 5, 6
  • Urinary obstruction 3
  • Admission to intensive care units 3, 6
• Treatment options for symptomatic Candida urinary tract infections include:
  • Fluconazole, which achieves high urine concentrations 2, 3, 4
  • Amphotericin B, which can be used as an alternative agent 2, 3, 6
  • Flucytosine, which can be used in combination with other agents 6
  • Nitroxoline, which has been shown to have antifungal activity against Candida species in urine 6